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Amputation

In general, amputation of limbs is the result of trauma, peripheral vascular disease, tumors, and congenital disorders. For the purpose of this plan of care, amputation refers to the surgical/traumatic removal of a limb. Upper-extremity amputations are generally due to trauma from industrial accidents. Reattachment surgery may be possible for fingers, hands, and arms. Lower-extremity amputations are performed much more frequently than upper-extremity amputations. Five levels are currently used in lowerextremity amputation: foot and ankle, below knee (BKA), knee disarticulation and above (thigh), knee-hip disarticulation; and hemipelvectomy and translumbar amputation. There are two types of amputations: (1) open (provisional), which requires strict aseptic techniques and later revisions, and (2) closed, or flap. Diagnostiq study assesment

X-rays: Identify skeletal abnormalities. CT scan: Identifies soft-tissue and bone destruction, neoplastic lesions, osteomyelitis, hematoma formation. Angiography and blood flow studies: Evaluate circulation/tissue perfusion problems and help predict potential for tissue healing after amputation. Doppler ultrasound, laser Doppler flowmetry: Performed to assess and measure blood flow. Transcutaneous oxygen pressure: Maps out areas of greater and lesser perfusion in the involved extremity. Thermography: Measures temperature differences in an ischemic limb at two sites: at the skin and center of the bone. The lower the difference between the two readings, the greater the chance for healing. Plethysmography: Segmental systolic BP measurements evaluate arterial blood flow. ESR: Elevation indicates inflammatory response. Wound cultures: Identify presence of infection and causative organism. WBC count/differential: Elevation and shift to left suggest infectious process. Biopsy: Confirms diagnosis of benign/malignant mass

NURSING CARE PLAN

Impaired Physical Mobility


Related to: Loss of a limb (particularly a lower extremity); pain/discomfort; perceptual impairment (altered sense of

balance)

Possibly evidenced by Reluctance to attempt movement

Impaired coordination; decreased muscle strength, control, and mass

Desired Outcomes: Verbalize understanding of individual situation, treatment regimen, and safety measures.

Maintain position of function as evidenced by absence of contractures. Demonstrate techniques/behaviors that enable resumption of activities. Display willingness to participate in activities.

Nursing Interventions Provide stump care on a routine basis, e.g., inspect area, cleanse and dry thoroughly, and rewrap stump with elastic bandage or air splint, or apply a stump shrinker (heavy stockinette sock), for delayed prosthesis. Measure circumference periodically Rewrap stump immediately with an elastic bandage, elevate if immediate/early cast is accidentally dislodged. Prepare for reapplication of cast. Assist with specified ROM exercises for both the affected and unaffected limbs beginning early in postoperative stage.

Rationale Provides opportunity to evaluate healing and note complications (unless covered by immediate prosthesis). Wrapping stump controls edema and helps form stump into conical shape to facilitate fitting of prosthesis. Note: Air splint may be preferred, because it permits visual inspection of the wound Measurement is done to estimate shrinkage to ensure proper fit of sock and prosthesis. Edema will occur rapidly, and rehabilitation can be delayed

Prevents contracture deformities, which can develop rapidly and could delay prosthesis usage. Increases muscle strength to Encourage active/isometric exercises for upper facilitate transfers/ambulation and promote torso and unaffected limbs. mobility and more normal lifestyle. Provide trochanter rolls as indicated. Prevents external rotation of lower-limb stump Strengthens extensor muscles and prevents Instruct patient to lie in prone position as flexion contracture of the hip, which can begin tolerated at least twice a day with pillow under to develop within 24 hr of sustained abdomen and lower-extremity stump. malpositioning. Use of pillows can cause permanent flexion Caution against keeping pillow under lowercontracture of hip; a dependent position of extremity stump or allowing BKA limb to hang stump impairs venous return and may increase dependently over side of bed or chair. edema formation. Facilitates self-care and patients Demonstrate/assist with transfer techniques and independence. Proper transfer techniques use of mobility aids, e.g., trapeze, crutches, or prevent shearing abrasions/dermal injury walker. related to scooting. Reduces potential for injury. Ambulation after Assist with ambulation. lower-limb amputation depends on timing of

Instruct patient in stump-conditioning exercises

Refer to rehabilitation team

Provide foam/flotation mattress.

prosthesis placement. Hardens the stump by toughening the skin and altering feedback of resected nerves to facilitate use of prosthesis. Provides for creation of exercise/activity program to meet individual needs and strengths, and identifies mobility functional aids to promote independence. Early use of a temporary prosthesis promotes activity and enhances general well-being/positive outlook. Note: Vocational counseling/retraining also may be indicated. Reduces pressure on skin/tissues that can impair circulation, potentiating risk of tissue ischemia/breakdown

Risk for Infection


Risk factors may include Inadequate primary defenses (broken skin, traumatized tissue)

Invasive procedures; environmental exposure Chronic disease, altered nutritional status

Desired Outcomes Achieve timely wound healing; be free of purulent drainage or erythema; and be afebrile.
Nursing Interventions Maintain aseptic technique when changing dressings/caring for wound. Inspect dressings and wound; note characteristics of drainage. Rationale Minimizes opportunity for introduction of bacteria. Early detection of developing infection provides opportunity for timely intervention and prevention of more serious complications. Hemovac, Jackson-Pratt drains facilitate removal of drainage, promoting wound healing and reducing risk of infection. Prevents contamination in lower-limb amputation. Maintains cleanliness, minimizes skin contaminants, and promotes healing of tender/fragile skin. Temperature elevation/tachycardia may reflect developing sepsis. Identifies presence of infection/specific organisms and

Maintain patency and routinely empty drainage device. Cover dressing with plastic when using the bedpan or if incontinent. Expose stump to air; wash with mild soap and water after dressings are discontinued. Monitor vital signs. Obtain wound/drainage cultures and sensitivities as

appropriate.

Administer antibiotics as indicated.

appropriate therapy. Wide-spectrum antibiotics may be used prophylactically, or antibiotic therapy may be geared toward specific organisms.

Situational Low Self-Esteem


May be related to Loss of body part/change in functional abilities Possibly evidenced by Anticipated changes in lifestyle; fear of rejection/reaction by others

Negative feelings about body, focus on past strength, function, or appearance Feelings of helplessness, powerlessness Preoccupation with missing body part, not looking at or touching stump Perceived change in usual patterns of responsibility/physical capacity to resume role

Desired Outcomes Begin to show adaptation and verbalize acceptance of self in situation (amputee).

Recognize and incorporate changes into self-concept in accurate manner without negating self-esteem. Develop realistic plans for adapting to new role/role modifications.

Nursing Interventions

Assess/consider patients preparation for and view of amputation.

Encourage expression of fears, negative feelings, and grief over loss of body part. Reinforce preoperative information including type/location of amputation, type of prosthetic fitting if appropriate (i.e., immediate, delayed), expected postoperative course, including pain control and rehabilitation. Assess degree of support available to patient. Ascertain individual strengths and identify

Rationale Research shows that amputation poses serious threats to patients psychological and psychosocial adjustment.Patient who views amputation as life-saving or reconstructive may be able to accept the new self more quickly.Patient with sudden traumatic amputation or who considers amputation to be the result of failure in other treatments is at greater risk for self-concept disturbances. Venting emotions helps patient begin to deal with the fact and reality of life without a limb. Provides opportunity for patient to question and assimilate information and begin to deal with changes in body image and function, which can facilitate postoperative recovery. Sufficient support by SO and friends can facilitate rehabilitation process. Helpful to build on strengths that are already

previous positive coping behaviors.

Encourage participation in ADLs. Provide opportunities to view/care for stump, using the moment to point out positive signs of healing.

Encourage/provide for visit by another amputee, especially one who is successfully rehabilitating. Note withdrawn behavior, negative self-talk, use of denial, or over concern with actual/perceived changes. Provide open environment for patient to discuss concerns about sexuality. Discuss availability of various resources, e.g., psychiatric/ sexual counseling, occupational therapist.

available for patient to use in coping with current situation. Promotes independence and enhances feelings of self worth. Although integration of stump into body image can take months or even years, looking at the stump and hearing positive comments (made in a normal, matterof-fact manner) can help patient with this acceptance. A peer who has been through a similar experience serves as a role model and can provide validity to comments and hope for recovery and a normal future. Identifies stage of grief/need for interventions. Promotes sharing of beliefs/values about sensitive subject, and identifies misconceptions/myths that may interfere with adjustment to situation. May need assistance for these concerns to facilitate optimal adaptation and rehabilitation.